A 59-year-old Lochearn woman died Monday of a rare infection after liposuction surgery, and two other patients have also contracted infections, prompting health officials Wednesday to shut down the Timonium cosmetic surgery center where each was treated.

Monarch Medspa officials are cooperating as Maryland and Baltimore County health officials investigate the source of the infections, which involve the same bacteria that causes strep throat. But the bacteria can be significantly more dangerous when infecting other parts of the body,sometimes causing shock, organ failure and even death.

In an order closing the center, state health officials said inspectors at the facility Tuesday observed "probable deviations from standard infection control practices."

The cluster of infections has prompted the state health department to consider whether it should increase oversight of cosmetic surgery centers. While doctors and nurses working in the centers must be board-certified, the centers themselves are not required to be licensed.

Health officials caution other patients who have visited the center in the past month to look out for symptoms such as fever, redness at a wound site, abrupt onset of pain, and swelling, dizziness, weakness and confusion.

A family member of the woman who died said she had visited the center for liposuction on or about Sept. 11. She returned the next day reporting extensive bleeding and was eventually sent home. By Thursday night, she was unable to keep her balance and called an ambulance. The family member would not name the patient and spoke on condition of anonymity because the woman did not want others to know she was undergoing liposuction.

She was taken to Northwest Hospital Center, where she went into cardiac arrest but was revived, and was then sent to University of Maryland Medical Center, where she died after medical staff were unable to stop the infection, the family member said.

Health officials would not provide any details about the identity of any of the patients who contracted infections, citing medical privacy laws. The other two patients were not hospitalized as of Wednesday, Baltimore County health department spokeswoman Monique Lyle said.

Monarch has been in business for eight years and operates five locations in Maryland, Pennsylvania and Delaware. The medspa performs all types of cosmetic surgeries, such as face lifts and breast augmentation, as well as Botox, laser hair removal and tattoo removal. The company has performed thousands of procedures safely over the years, officials said in a statement.

"Monarch's primary concern is for the safety and well-being of all of our patients, and we extend our deepest sympathy to deceased patient's family," the statement said. "The suspected infections are a new development and their possible origins are being closely and carefully investigated."

Plastic surgeons said that in liposuction procedures, as in any surgeries, sterilization is key in preventing infections in patients. But a disease expert said, given the type of bacteria involved, it's more likely that someone in the operating room was a carrier of the bacteria.

The surgery typically involves making small incisions around the area of the body to be thinned and inserting tubes between the skin and other tissues. Fluids to clean the tissue and decrease bleeding are introduced, inflating the skin to allow the tubes to suck out excess fat. After the fat is removed, the incisions are closed with stitches.

Dr. Michele Manahan, a plastic surgeon at Johns Hopkins Medicine, said it's important to ensure that the tubes are sterile, as well as the fluid, the patient's skin, cloths draped over the skin, and anything else used in the surgery is sterile. But there always is a chance of introducing bacteria into a patient.

"Even in a perfect situation, surgery carries risk," Manahan said.

If bacteria is introduced during liposuction and an infection forms, treating it can be challenging when it is deep within tissue, said Dr. Michael Cohen, founder and medical director of the Cosmetic Surgery Center of Maryland in Towson.

But infections involving the type of bacteria in these cases are rare in plastic surgery, said Trish Perl, senior epidemiologist for the Johns Hopkins Heath System. The bacteria, known as group A streptococcus, can be particularly harmful in skin infections but are rarely found living on medical tools or elsewhere in the environment, outside the body.

"In general when we see this infection with clusters or outbreaks, it's related to a carrier," said Perl, referring to a person who carries the bacteria, often unknowingly. The bacteria is typically spread through droplets, such as saliva, and often requires treatment with antibiotics, she said. When found outside the body, it typically can be removed with soap and water, she said.

Over the past five years, about 189 cases of invasive streptococcus infections have been reported each year in Maryland. About 9,000 to 11,500 cases occur each year across the country, causing 1,000 to 1,800 deaths annually, health officials said.

Health officials said they plan to seek public input on whether more oversight of cosmetic surgery centers is needed. They did not give a timeline for the investigation into Monarch.

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